complaint·August 29, 2025

In regards to the allegation that staff did not properly report incidents involving residents, information obtained from interview with Additional Witness 1 (AW1) disclosed that several incidents involving resident on resident altercations were advised of by witnesses not associated to the facility. Interview with AW2 stated mandatory reporting requirements were discussed with ED on two separate occasions. AW2 further reported that they had provided staff with resources outlining the LTCO reporting guidelines. Information obtained from interview with ED, revealed that 6 of 6 incidents were reported to CCLD, however, the same reports were not provided to LTCO. ED explained that there was a lack of understanding regarding LTCO reporting requirements. ED reported that clarification was provided to facility staff. Interview with additional staff (S1) shared that they were assigned responsibility for incident reporting beginning in January 2025. S1 confirmed that incident reports were submitted to CCLD in accordance with regulatory requirements, but not to LTCO. Through a review of records, LPA observed that 6 out 6 incidents that occurred during January 2025 through March 2025, which met LTCO reporting requirements, were not cross-reported to the LTCO. This poses as a potential health & safety risk to residents in care. For the allegation that staff do not prevent resident to resident altercations while in care, LPA interviewed staff and witnesses, and obtained supportive documentation to aid in determining the findings of the noted allegation. During an interview with ED, it was reported that incidents involving memory care residents can be unpredictable due to behavioral factors. ED added that staff receive initial training, as well as ongoing in-service trainings, to ensure they are equipped to understand and appropriately respond to behavioral incidents. LPA reviewed facility in-service training records which revealed staff received training on various topics, including resident observation, dementia redirection techniques, responding to call buttons, hydration practices, monitoring physical changes, and conducting resident reappraisals. LPA noted that in-house training records commenced in May to August 2025 and subsequently requested documentation covering the period from January to March 2025. Interview with ED stated that those were the records available at this time. A review of facility records between the period of January 2025 through March 2025 was conducted. The record review revealed a total of 6 incidents that met the criteria of resident on resident altercation. LPA observed that 6 out of 6 incidents documented staff intervened by separating the involved residents, redirecting behavior, and/or conducting assessments for potential injuries. Documentation also revealed that there were four residents who were repeatedly involved in the identified 6 altercations. Continued LIC 9099-C. ED reported the facility’s response included several interventions to manage these behaviors, which included requesting revised physician orders, adjusting medications, and conducting resident reassessments. LPA also examined the facility’s activities calendar, which provides a structured daily schedule of programs available to residents under care. Interviews conducted with 6 of 6 staff members revealed inconsistencies regarding the ED statement on implementation of training and behavioral interventions during the period of January through March 2025. Through interviews it was revealed that no in-house training was provided on preventing resident-to-resident altercations during the time frame. Additionally, staff consistently reported that the practice of redirecting residents was insufficient as a standalone method for managing individuals with behavioral challenges. Concerns were also advised regarding staffing levels, which were described as inadequate for effective resident supervision. Examples were cited, including concerns with Villa 2, which accommodates up to 18 residents. Staff noted that at times, only one employee was assigned to this unit, significantly limiting the ability to respond promptly to incidents while simultaneously attending to other residents. An additional concern identified was the lack of staffing coverage resulting from last-minute call-outs. Staff interviews indicated that these absences were not consistently backfilled, leading to inadequate staff-to-resident ratios. This shortage compromised both the safety and the level of supervision provided to residents in care. This poses as a potential health & safety risk to residents in care. Based on interviews and record reviews, the allegation that staff did not properly report incidents involving the residents and staff do not prevent resident to resident altercations while in care is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The facility will be cited. An exit interview was conducted. A copy of this report, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided to Executive Director Valeria Garcia.